<i>Respirology</i> year‐in‐review 2007: Clinical science

Respirology continues to serve as the pre-eminent regional respiratory journal for Asian and Pacific countries and submissions have continued to increase, as has the quality of published papers. Rather than reporting mostly descriptive data, many authors have endeavoured to also examine disease mechanisms with the aim of improving our understanding of the underlying disease process. We are starting to move from descriptions of the disease and where it occurs to a more developed style able to provide mechanistic information that may ultimately contribute to the development of treatment solutions and better disease management. The shift in emphasis reflects a growing maturity of Respirology and indicates that as an academic journal it can contribute significantly to future dissemination of new scientific knowledge related to respiratory diseases. It is expected that this ‘maturity’ will encourage authors to send their ‘good’ papers first to Respirology and indeed the journal is now receiving many manuscripts from areas outside of our traditional support base. In this review we highlight important findings in clinical sciences from articles published in Respirology in 2007. We hope it will provide an overview of new information reported in the journal that will facilitate gains in our understanding of respiratory diseases. Characterization of different disease phenotypes remains a research priority in asthma.1 Ceylan et al. studied the association of nasal polyps with asthma and found that patients with polyps had increased asthma severity, suggesting the presence of a ‘united airway’ and implying close links between inflammatory diseases affecting the upper and lower airways.2 Severe or ‘difficult’ asthma was evaluated in a study conducted in a specialist asthma clinic, and again the severe phenotype was linked to an impaired quality of life.3 The study also showed that the severity of impairment is likely to be underestimated by clinicians managing patients in busy outpatient departments. An interesting study by Talay et al. found increased Gram-negative bacterial colonization in older asthmatics with more severe disease.4 Although all patients were current non-smokers, previous smoking was not reported and the cohort may have been biased by the inclusion of ex-smokers having COPD, a group with known increased bacterial colonization.5 Studies of environmental factors that influence the development of asthma have suggested that exposure to endotoxin may bias the immune response away from asthma. This hypothesis was assessed in a longitudinal Canadian study, conducted over a period of 2 years.6 The data demonstrated a reduced risk of asthma in a farming environment, with odds ratios of 0.22 (parental asthma) and 0.39 (no parental asthma). This study expands the findings from previous observational studies in the field. Asthma outcomes and management were evaluated in an Australian study that covered all states (metropolitan and rural) by Marks and colleagues.7 They obtained responses to a detailed questionnaire from 70% of the study group initially identified for inclusion, and showed that asthma control was generally poor. Rather disturbingly, they found that only 35% of adult asthmatics with daily symptoms were taking inhaled corticosteroids. Although the study was conducted in one country and may not necessarily be representative of the Asia–Pacific region, it nevertheless indicates that asthma management and treatment may be suboptimal in many countries. An intriguing study performed by Lancsar and coworkers assessed patient preferences in relation to three options: current inhaled steroid medication, a hypothetical preventer and no medication.8 This entailed a discrete choice experiment in 57 adults with mild–moderate asthma who were using ≤500 μg beclomethasone (BDP) or equivalent medication. The results suggested that patients prefer anti-inflammatory medications that maximize physical activities, have few side-effects and do not require daily PEF measurements. The results provide a timely reminder that asthma patients may have priorities that are different from those traditionally espoused by medical professionals. Finally, two studies evaluated the efficacy and side-effects of a new inhaled corticosteroid, ciclesonide.9,10 Hydrofluoroalkane-ciclesonide, 800 μg daily was more efficacious than chlorofluorocarbon-BDP, 800 μg daily in reducing asthma symptoms and increasing PEF. Side-effects were similar in the two treatment groups and occurred in few patients. Interstitial lung disease (ILD) remains under researched and continues to present ongoing clinical, therapeutic and prognostic challenges to respiratory physicians. Although some basic research indicates the nature of the underlying lung fibrotic process, there is limited information to help the clinician choose an effective treatment and provide the patient with an accurate indication of their disease course and ultimate prognosis. However, several studies published in Respirology in 2007 have added valuable information regarding prevalence, putative causes and diagnosis of ILD. Anantham and coworkers studied the incidence of sarcoidosis in a large Singapore hospital.11 They detected a higher incidence and more severe disease in patients of Indian ethnicity, a finding that is comparable to observations made in African-American populations. A study conducted in Turkey found the highest frequency of onset of sarcoidosis in spring, again suggesting a role for an infectious agent and further studies appear warranted.12 Patients with IPF are prone to acute exacerbations that have been mostly ascribed to infections. Infections with Chlamydophila (previously Chlamydia) pneumoniae are thought to be an important cause of both asthma and COPD exacerbations and were evaluated in patients with acute ILD.13 The authors used acute and convalescent serology to detect infections, and only a small number of cases were associated with significant rises in antibody titres, suggesting a limited role for this organism in acute ILD. The study did not use PCR methods to assess C. pneumoniae in sputum and may have failed to detect mild infections. PET is now widely used to stage lung cancer but may also have utility in ILD, reflecting the high inflammatory burden. Nusair and coworkers used PET to evaluate whether IPF can be distinguished from other ILD by this method.14 The findings were disappointing and did not allow differentiation of IPF from other ILD. Larger study populations and use of newer technologies may be required in assessing the utility of PET in ILD. Real-time endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a new technique with a sensitivity >90% for diagnosis of mediastinal and hilar malignancies. A study by Oki et al. found EBUS-TBNA to be highly sensitive in the context of suspected sarcoidosis with mediastinal and/or hilar lymphadenopathy.15 The procedure was safe and devoid of significant morbidity, and larger studies are warranted. A feature of papers published in Respirology in 2007 has been an emphasis on characterizing pleural effusions associated with a variety of medical conditions. Porcel and coworkers studied 230 consecutive patients with pulmonary embolism and detected pleural fluid in about one-third.16 All effusions were exudates, often with high erythrocyte counts. Surprisingly, the presence of pleural fluid was not related to radiological evidence of pulmonary infarction (50% in those with signs of infarction, 46% in patients without, P = 0.7). The prevalence of pleural effusion post orthotopic heart transplantation (OHT) was evaluated in another study.17 The authors reported that pleural effusions were common within 12 months following OHT (85%) and that most were small, bilateral and tended to resolve. Peng and coworkers evaluated symptomatic large pleural effusions more than 30 days after coronary artery bypass grafting.18 The prevalence of effusions was low (approximately 3%) and again most resolved with medical management. Diagnostic and therapeutic modalities for simplifying traditional diagnostic pathways in pleural effusions of unknown origin continue to evolve. Lee and coworkers reported a prospective evaluation of flex-rigid pleuroscopy for diagnosis of indeterminate pleural effusion.19 Patients who had received no diagnosis after at least one thoracocentesis and one closed needle pleural biopsy were studied. Flex-rigid pleuroscopy yielded a diagnosis in 49/51 patients and morbidity was minimal. In a report by Luh and Tsao treatment of was evaluated using The of was by in of patients and was required or to control ongoing in only about of patients. 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